Healthcare Provider Details

I. General information

NPI: 1669318093
Provider Name (Legal Business Name): JADE HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7912 WHISTLE CREEK CT
BYRON CENTER MI
49315-9185
US

IV. Provider business mailing address

7912 WHISTLE CREEK CT
BYRON CENTER MI
49315-9185
US

V. Phone/Fax

Practice location:
  • Phone: 616-212-0081
  • Fax:
Mailing address:
  • Phone: 616-212-0081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA WANG
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 616-212-0081